New report calls for U.S. universal coverage of long-term care for older adults

Participants in Pennsylvania Department of Aging’s SHARE housing program during pandemic

Photo: Governor Tom Wolf via Flickr

The heavy toll that the COVID-19 pandemic has taken on older Americans highlights the need to strengthen the nation’s safety net for those requiring long-term services and supports, according to a new report in the Milbank Quarterly.

The report proposes a system of universal coverage to support long-term care for all older Americans. But we’ve been down this road before — trying for decades to create a viable, cohesive long-term care system. What makes anyone think things will be different this time around?

The COVID-19 pandemic could be an inflection point toward improving the nation’s long-term services and supports system (LTSS), according to lead author Walt Dawson, D.Phil., assistant professor of neurology in the Oregon Health Sciences University School of Medicine.

“Protecting against financial catastrophe and ending the current system that requires people to be financially destitute to access coverage via Medicaid would benefit both individuals and families and would also create a far more stable and more generous funding stream to providers,” Dawson and his colleagues wrote.

The report lays out a series of recommendations to repair what it characterized as a fragmented and patchwork system of long-term services and supports for older Americans, especially those living with physical and cognitive impairments.

“It is essential to keep the idea of some type of universal way of supporting the middle class and modest class,” said co-author Robyn Stone, senior vice president, research and co-director, LeadingAge LTSS Center at UMass Boston. Stone worked on one of the first bipartisan efforts at LTSS with the Pepper Commission in 1989.

COVID-19 has highlighted the serious challenges of our LTSS system, she said. “It’s important to have the message out there. We need to be thinking about this as part of a constellation of solutions to what we know is a current challenge, and that’s going to continue to be especially challenging as we see the 85-and-over population growing.”

Long-term recommendations

  • Universal coverage: The report calls for establishing universal coverage for all Americans’ long-term care needs through Medicare. “Universal coverage is essential to achieving greater equity in access and coverage, but it is also essential to the fiscal viability of the financing mechanism (e.g., everyone pays into the system),” the authors write.
  • Creating an age-friendly health system: The report calls for better collaboration between public health, health care systems, and long-term care to safeguard older adults’ health and safety.

Near-term recommendations

  • Improved reporting of COVID-19 infections: The report calls for improving a “lack of publicly available information” nationally about COVID-19 infections among people receiving long-term services and supports and the workforce caring for them.
  • Support for unpaid caregivers: Family caregivers could be identified through Medicare and compensated at the rate of home health aides. Also, the report calls for improved lines of communication between acute care facilities and other forms of long-term services and support.
  • Equitable treatment: The Medicaid reimbursement system should provide resources to support independent long-term care and home care providers who often care for the most vulnerable and medically fragile older adults.

“We have to really recognize that longevity brings with it some years of disability and functional needs, in addition to chronic illness and that it’s not going to go away. We have to have good options. And we have to be able to have at least some way of helping us to pay for it,” said Stone.

Federal administrative action can address some of these issues and states also do some things, but they’re going to be financially strapped, according to Stone. So, the notion that they’re somehow going to be raising additional monies for long-term services is out of the question right now. More federal-state collaboration is necessary going forward.

“I’ve been extremely disappointed that we have had so little investment in public health in this country relative to other countries, and where we have invested, there hasn’t been very much investment at all in older adults,” she said. “This pandemic is an example of not being able to respond quickly to the needs of particular populations. There’s no capacity. There’s no knowledge.”

One of the goals of writing this report is to keep the need for improved LTSS and a more robust safety net top of mind among policymakers. Another purpose is to encourage LTSS and public health systems to work together better at the local or state level, according to Stone. Doing so can provide better prevention and early intervention and possibly improve integration, or at least coordination, of medical care.

“Although these are not new problems, the pandemic has exacerbated and amplified their impact to a point that they are impossible to ignore,” the report concludes. “The opportunity for reform is now.”

Here are some questions to answer in your reporting on this issue:

  • How are your local and state public health systems and long-term care services collaborating on helping older adults — whether in the community or at long-term care facilities?
  • How are vaccines being administered to older people who are homebound or have difficulty traveling to a mass vaccination site?
  • What is being done to coordinate and assist with preventive care through delivery mechanisms like telehealth?

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